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Q: Renal failure and dementia ( Answered,   0 Comments )
Subject: Renal failure and dementia
Category: Health > Conditions and Diseases
Asked by: sickfather-ga
List Price: $10.00
Posted: 13 May 2005 07:19 PDT
Expires: 12 Jun 2005 07:19 PDT
Question ID: 521269
My father has end stage renal failure. He states that he doesn't want
to die, but will not stay on dialysis for a full treatment.  This
causes him to become demeted and scream 24 hours a day.  We have tried
sedating him but he still starts yelling to get off about an hour
early.  Do you have any suggestions for what to do now.  The only way
we can keep him on is to have one of his grand children sit with him.
About every three to four weeks we get into crisis with too much fluid
or too many toxins.  We don't know what else to do.  should we just
stop trying to keep him alive since he won't stay on?  When he is
lucid, he says he wants to live, but he stays in bed about 21 hours a
day.  He only gets up when we force him to.  He is not eating.
Subject: Re: Renal failure and dementia
Answered By: crabcakes-ga on 13 May 2005 12:15 PDT
Hello sickfather, 

   What a dilemma you are facing! Have you discussed how best to
handle this situation with your dad?s physician? Have you discussed
putting your father on an anti-anxiety medication on a regular basis,
and not just sedate your father for dialysis day?

?Psychiatrists can prescribe highly effective medications that relieve
the fear, help end the physical symptoms such as pounding heart and
shortness of breath, and give people a greater sense of control.
Psychiatrists often prescribe one of the benzodiazepines, a group of
tranquilizers that can reduce debilitating symptoms and enable a
person to concentrate on coping with his or her illness. With a
greater sense of control, the person can learn how to reduce the
stress that can trigger anxiety, developing new behaviors that will
lessen the effects of the anxiety disorder.?

Decisions would need to be made between you, your father and his
doctors, depending on his wishes, his age, and how advanced his ESRD
is. Has your father expressed his end of life wishes with you? Does he
have a living will? Would he want his life prolonged? While dialysis
is not painful, many patients experience a drop in blood pressure,
headaches and nausea. Your dad may want to avoid this discomfort.

?Despite thrice weekly hemodialysis treatments or daily peritoneal
dialysis treatments, dialysis does not restore full health. There is a
prevalent sense among the general public that life on dialysis is very
difficult, that it is painful and depressing, that dialysis patients
are weak and tired, and that for very old and debilitated patients
perhaps life on dialysis is not worth living. "What's the quality of
life? I'd never want to live like that, hooked up to a machine."

When chronic dialysis was first introduced in the 1960s, the extreme
nature of the treatment prompted investigation of its emotional impact
on the patients. There is now an annual meeting on "psychonephrology."
Psychosocial counselling is an integral part of ESRD treatment,
although in the U.S. the social worker's counselling role has in most
settings been progressively diluted by administrative roles and
financial constraints. Patients often consider withdrawing from
treatment, thinking that death might be a preferable option.
Approximately 20% of patients on dialysis elect to discontinue the
treatment, preferring death, p.98.

ESRD treatment involves making choices among options, and these
options entail real tradeoffs. First, there is the decision whether to
take on the burdens of treatment to achieve longer survival. This
decision depends in turn on what those burdens are and how they can be
expected to affect the person. For younger patients this may be
straight-forward. But older individuals might interpret renal failure
as a natural conclusion to their lives. Second, there is the timing of
treatment. Should one have a pre-emptive transplant to avoid dialysis
altogether? If so, at what level of kidney function? (How much longer
could one have waited?) Should one begin dialysis only when there are
intractable physiologic and metabolic complications? Alternatively,
will an early or "healthy" beginning of dialysis prolong survival? How
does one balance the psychological loss and the morbidity of earlier
treatment against longer survival? How does one choose between
hemodialysis and peritoneal dialysis? One may face choices about
dialysis dosing. For many patients, longer hemodialysis treatments and
more frequent or larger infusions of peritoneal dialysate will prolong
survival. But at what discomfort, at the cost of what change in
life-style? What will the cost be in the quality of the patient's

Is your father a candidate for a kidney transplant? Have you discussed
this possibility with the doctors?

?Kidney Transplants -- A functioning kidney transplant provides the
diabetic patient, whose kidneys are failing, better survival with
superior rehabilitation than does either CAPD or maintenance
hemodialysis. Fewer than four in 100 diabetic ESRD patients treated by
either peritoneal or hemodialysis will live for a decade while cadaver
donor and living donor kidney recipients fare far better. More than
half of diabetic kidney transplant recipients live for at least three
years. Many survivors return to occupational, school and home

Could you place your father in a nursing home? Perhaps if he didn?t
have to travel to receive dialysis, he would be more prone to
accepting it. Has he received some mental health counseling? Family
members can rotate ?turns? at sitting with Grandpa. Have the
grandchildren make a journal. Each child can ?interview? Grandpa, and
write down his stories and life history. This will document family
history, help pass the time, distract Grandpa,  and allow the children
to better know their grandfather.

Could your father have his treatment at home? Your doctor, or one the
kidney organizations can assist with home care.

Many dialysis patients undergo multiple stress factors, from the
dialysis procedures themselves, as well as independence loss and
lifestyle restrictions, causing  anxiety and depression. Additionally,
as you stated, an increase in metabolic waste that accumulates in the
bloodstream (toxins and fluids) can cause or exacerbate some forms of
dementia and/or altered level of consciousness.

The following link is to an article, found on pages 3 and 4, that
discusses depression, dementia, and anxiety in ESRD patients. (It is

Unfortunately, without paying, we can not read the rest of this
article ?Psychiatric illness in dialysis patients? by Rebecca J
Schmidt, DO, FACP and Jean L Holley, MD, FACP :
?Patients maintained on hemodialysis are more likely to be
hospitalized for a psychiatric disorder than are those treated with
peritoneal dialysis. This difference may be due to patient selection
for a particular dialysis modality or the increased incidence among
hemodialysis patients of disruptive behaviors that may lead to
hospitalization [1]. Overall, the type of dialysis modality does not
appear to have a significant impact upon symptoms related to
depression, sexual function, and life satisfaction [2].

There are a paucity of data relating to the effectiveness of
therapeutic interventions in the treatment of psychiatric disorders
occurring in patients with ESRD. It is unclear if the management is
less successful and, thus, hospitalization is more common. Resistance
to therapy may also contribute to higher hospitalization rates.

Although few studies relating to the treatment of depression or other
psychiatric disorders occurring in patients with ESRD exist, general
recommendations for treating such individuals based upon outcomes
among those without renal failure can be made.?

You say your father is not eating. Inadequate nutrition can make your
father feel poorly, and not want to get up. If he won?t eat, will he
drink Ensure or similar liquid nutrition? Anemia and calcium/Vitamin D
deficiency is common in dialysis patients.

?Anemia is one of the side-effects but it responds to new
genetically-engineered drugs like erythropoietin which stimulates red
blood cell production. Another side-effect, metabolic bone disease,
caused by the loss of bone minerals, is minimized by treatment with
synthetic vitamin D. Motivated patients trained to perform
self-hemodialysis at home gain the longest survival and best
rehabilitation afforded by any dialytic therapy for diabetic ESRD.?

Quality of Life in ESRD

Dialysis and ESRD

I hope this has helped you and your father. I wish I could give you
concrete advice, but there are too many variables. Your father?s
mental status, his age, other medical history and his and the family?s
wishes all need to be considered. Please discuss this with your
father?s doctor for further assistance with any decisions which need
to be made.

If any part of my answer is unclear, please request an Answer
Clarification, before rating. This will allow me to assist you

I wish you and your family all the best.
Sincerely, Crabcakes

Search Terms
ESRD + options
ESRD + quality life

Clarification of Answer by crabcakes-ga on 13 May 2005 12:47 PDT
Hi again Sickfather,

 I inadvertently left off these two links, both of which you may find useful.

End of Life decisions and renal dialysis

This is a ESRD forum, that has some good reading and links:

Regards, Crabcakes

Request for Answer Clarification by sickfather-ga on 14 May 2005 05:38 PDT
Crabcakes, thank you for your answers.  My father is 85 and everything
you suggested we have tried including the daily anitdepressives,
anti-anxiety meds, the nursing home route, the journal writng of the
history, DVD player, tape players, all of it.  His doctor says he
feels dad is ambivlaent about life or death and that we should  er o
the side of life and keep trying to mak him comfortable.  We have
given him an appetitle stimulate in the past and have ask for one
again.  If he wants to stop treatment we will support him, but he says
he knows he will die and doesn't want to.  The problem is sitting
through 12 hours of treatment a week.  We have shortened the sessions
to 3 hours 4 times a week instead of 4 hour 3 times.
Any other ides? I wil read the links.  Thanks for the help.

Clarification of Answer by crabcakes-ga on 14 May 2005 20:57 PDT
Hi sickfather,

  Thank you for your clarification. Wow... you seem to have covered
all the bases. I too am at a loss. Your father says he does not want
to die, yet seems to reject steps to save him.

  I have two more suggestions. Well, two and a half suggestions.
Have you considered nocturnal dialysis? That would be dialysis while
your dad is sleeping. The 'half' an idea would be to have his dialysis
done at home. Your local hospital can direct you to information on
these services in your area.

If you go to Google,  ://       and enter your zip
code and home dialysis you will probably find places to call for more

11111 + home dialysis     

In another search enter your zip code and nocturnal dialysis

11111 + nocturnal dialysis

I found many in my area this way.

Sleeping with Dialysis:
   "Nocturnal hemodialysis is designed to shorten the time between
dialysis sessions, usually 6 nights per week, and lengthen the time of
dialysis, usually 8 hours, so that there is less accumulated waste and
fluid to remove over a longer period of time.  This leads to a gentler
treatment which is better tolerated by most patients.  Nocturnal
hemodialysis is performed by the patient at home after sufficient
training and certification.  Not all patients are good candidates for
nocturnal hemodialysis as it takes motivation to care for oneself and
attention to detail and procedure to perform a safe and effective
dialysis treatment for oneself."

Locations that perform nocturnal dialysis:

Another idea is to talk to his priest/rabbi/minister and see if he can
talk your father into complying with his dialysis and meal regimen.
Perhaps he can make your father understand that if he does not wish to
die now, he must comply with the dialysis and also eat.

 Parenteral nutrition (TPN) can be tried to get some lipids, proteins
and vitamins into your dad. This is where  a semi-permanent feeding
tube is inserted into the bloodstream, and infuse a clear nutritious

If none of the above is feasable, I'm afraid you will have to remain
patient and continue on with the situation as is. Take care of your
father as well as you can, and continually remind your father that in
order to live, he must eat and continue dialysis.

Again, I wish you and he the best. Sincerely, Crabcakes
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